ZPPP Plus GAHM For Severe OSAHS

Objective To explore feasibility of Z-palatopharyngoplasty (ZPPP) plus genioglossus advancement and hyoid suspension (GAHM) for severe obstructive sleep apnea hypopnea syndrome (OSAHS), Study was designed to assess the safety and efficiency of this new procedure. Specific indicators included reorganization of sleep architecture. In order to find effective surgical approaches for patients with severe OSAHS who suffer from oropharyngeal and hypopharyngeal obstruction.Materials and Methods From July 2006 to June 2007, 26 subjects with severe OSAHS diagnosed by polysomnography(PSG) were recruited at the Sleep Center of the Affiliated Sixth People's Hospital of Shanghai Jiao Tong University,At same time, 26 subjects according to these criteria: (1) persistent symptoms suggesting OSAHS and an apnea-hypopnea index(AHI) > 40, as determined by PSG; (2) obstruction in both the oropharynx and the hypopharynx were determined by preoperative physical examination, fiberoptic pharyngolaryngoscopy, cephalometry, and computed tomography of the upper airway. Cephalometric analysis was performed according to standard criteria, and retrolingual narrowing was defined as a posterior airway space (PAS) <11 mm, At the same time, lowered hyoid position was defined as a MP-H>15mm (3) Nasal continuous positive airway pressure(nCPAP)intolerance for long term therapy (4) no severe medical diseases and in good general health. The subjects ranged in age from 37 to 61 years, with a mean age of 47.69 years (SD = 8.16). The 22 patients were male, the others were female. The mean body mass index (BMI) was 29.46kg/m2(SD =2.54). The subjects underwent nasal CPAP for 5 to 7 days as planned and then received the combined surgical procedure under general anesthesia. During the 24h following surgery, the patients were monitored in the surgical intensive care unit. All patients were reevaluated with the preoperative methods at 6 months after surgery. Total arousal index, respiratory-related arousal index, AHI, percent of CT90, Scores of Health-related Quality of Life, LSaO2, CT90 and ESS, Their correlations were analyzed. Data were analyzed using SPSS 13.0 for Windows.Results Complications of ZPPP plus GAHM were rare. Temporary postoperative velopharyngeal insufficiency was as same as UPPP plus GAHM. Postoperative 6 months, ESS was reduced from preoperative 13.54±5.94 to 6.85±5.24(p<0.05),Snoring was reduced from 5.38±3.61 to 2.85±2.15(p<0.05). Scores of Health-related Quality of Life were improved. There was a statistically significant reduction in the AHI (preoperative: 65.58±17.56; postoperative: 30.08±23.05). Oximetric analysis demonstrated a statistically significant decrease in CT90 (preoperative: 122.08±102.42; postoperative:59.62±101.88), Percent of CT90 was decreased from preoperative 30.99±28.13% to postoperative 15.52±25.55% ( p<0.01 ), The lowest oxyhemoglobin saturation (LSaO2) from 73.85±9.04% to 82.77±7.33%(p<0.01),At the same time, sleep architecture were effectively changed, The S3+S4 percent of total sleep time (TST) increased from 3.55±4.37% to 8.69±5.02% (p<0.05), Respiratory-related arousal index was reduced from 39.03±25.21 to 14.74±13.71 (p<0.01). The correlation analysis of the pre/postoperative changes observed in the arousals studies revealed that respiratory-related arousal index was related to ESS, scores of Health-related Quality of Life, AHI, CT90 and percent of CT90. And arousal index was related to ESS and AHI, but not to scores of Health-related Quality of Life, CT90 and percent of CT90. Successful treatment of patients with Friedman OSA stages II was 100%, The overall success rate of Friedman OSA stages III was 22.2%. Successful treatment of patients with tongue position II was 100%, Success rate of tongue position III was 33.3%, No patients with tongue position IV were successful. Clearly, patients with Friedman OSA stages II or tongue position II disease had the best success rate. The mean postoperative BMI was 28.15kg/m2 (SD = 2.46), No significant change was seen between the postoperative and preoperative BMI values.Conclusion ZPPP plus GAHM for patients with severe OSAHS who suffer from oropharyngeal and hypopharyngeal obstruction is more successful with acceptable morbidity and safety. It obviously decreased AHI,ESS,CT90 and respiratory-related arousals. Postoperative scores of Health-related Quality of Life were improved. Correspondingly, sleep architecture is reorganized, which is expressed postoperatively as an increase in slow wave sleep. Moreover, Friedman OSA stages and tongue position can predict success rate of ZPPP plus GAHM. We suggest that GAHM plus ZPPP might serve as a potential alternative to the patients with severe OSAHS who suffer from oropharyngeal and hypopharyngeal obstruction. Studies are needed to examine the efficacy of ZPPP plus GAHM.